Provider Demographics
NPI:1457445751
Name:MERCY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:MERCY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:HOMECARE CONNECTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF BUSINESS DEVELOPMENT & STRATE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-240-1717
Mailing Address - Street 1:1070 N MONROE ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162
Mailing Address - Country:US
Mailing Address - Phone:734-240-1717
Mailing Address - Fax:734-240-1715
Practice Address - Street 1:1070 N. MONROE ST
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162
Practice Address - Country:US
Practice Address - Phone:734-240-1717
Practice Address - Fax:734-240-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI580030251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3106694Medicaid
MIOE074OtherBLUE CROSS
MI0E074OtherBLUE CROSS
MI3222414Medicaid
MI0E074OtherBLUE CROSS
MI231573Medicare UPIN